Found in bile canaliculi (but also in placenta, ileal mucosa, bone, and kidney)

Elevated in diseases of cholestasis

Rare for levels to be >3x normal limit in acute liver failure

Bilirubin

Elevated in diseases of cholestasis

In obstructive diseases, the direct bilirubin will usually be about 50% of the total bilirubin; if indirect bilirubin is higher, more suggestive of hemolysis or problem with conjugation

Coagulation Studies

Reflects the liver’s ability to synthesize clotting factors

INR >6.5 or PT >20 seconds indicates patients at high risk for death

Albumin

Reflects synthetic function of the liver

Has a long half-life (20 days) and may not be decreased early in disease

Ammonia

Elevated as a result of impaired clearance

Poor correlation between degree of elevation and severity of encephalopathy symptoms

Chemistry Panel

Electrolyte abnormalities may indicate malnutrition or dehydration

Creatinine is used as a prognostic indicator

Need to check a glucose because patients with liver failure are prone to hypoglycemia

CBC

Not useful in diagnosing the cause of liver failure, but helpful in determining coexisting infection, anemia, thrombocytopenia

Hepatic Viral Serologies

Consider for all patients with undifferentiated liver failure

IgM anti-HBc may be the only positive marker in acute Hepatitis B infection

Anti-HCV and HCV RNA are present in both chronic and acute Hepatitis C infections, so it is difficult to differentiate based on serologies, but presence of HCV RNA in the absence of anti-HCV is more suggestive of acute infection[8]

Only need to test for IgM anti-HEV in patients who are symptomatic and have just travelled from areas where Hepatitis E is endemic

Imaging

Consider RUQ US or CT in patients with jaundice to evaluate for a mechanical obstruction

Otherwise, tailor imaging towards specific complaints

Management

Treatment is mostly supportive and tailored towards the specific etiology

Early consideration regarding transporting patient to a transplant center given potential for rapid deterioration